1. 17th October 2012 Dr Julian Tomkinson
Breaking Bad News
17th October 2012
Dr Julian Tomkinson

2. What is Bad News?
"any information which adversely and seriously affects an individual's view of his or her future"

3. Why is it Important? A Frequent but Stressful Task
Breaking bad news can be particularly stressful when the doctor is inexperienced, the patient is young, or there are limited prospects for successful treatment

4. Patients Want the Truth
By the late 1970s most physicians were open about telling cancer patients their diagnosis .
In 1982 of 1,251 Americans indicated that 96% wished to be told if they had a diagnosis of cancer
85% wished, in cases of a grave prognosis, to be given a realistic estimate of how long they had to live

5. Ethical and Legal Imperatives
Clear ethical and legal obligations to provide patients with as much information as they desire about their illness and its treatment
Physicians may not withhold medical information even if they suspect it will have a negative effect on the patient

6. Clinical Outcomes
How bad news is discussed can affect the patient's comprehension of information, satisfaction with medical care, level of hopefulness, and subsequent psychological adjustment

7. Barriers to Breaking Bad News
Emotion – anxiety
Burden of responsibility
Fear of negative evaluation

8. Models for Breaking Bad News
SPIKES model
Robert Buckman
Professor of Oncology – Toronto
Trained in Cambridge
Used world wide
KAYES model

9. SPIKES Model Six steps S – Setting up the interview
P – assessing the patients Perception
I – obtaining the patients Invitation
K – giving Knowledge
E – addressing Emotions
S – Strategy and Summary

10. S – Setting up the interview
Privacy
Involve others
Look attentive and calm
Listening mode
Availability

11. P - Perception
Ask before you tell
Find out what the patient knows
ICE

12. I – Invitation
While a majority of patients express a desire for full information about their diagnosis, prognosis, and details of their illness, some patients do not
How much information would the patient like to know

13. K – Knowledge Warning first Mirror language Avoid jargon Small chunks
Use of silence
Allow time for emotions

14. E – Emotions Recognise Listen for and identify the emotion
Identify the cause of the emotion
Show the patient you have identified both the emotion and its origin

15. S – Strategy and Summary
Understanding reduces fear
Summarise the discussion
Strategy for future care
Schedule next meeting
Allow time for questions
Leaflets

16. Kaye’s Model 10 steps Logical sequence Not based on rigorous research
Can be used for any serious illness
Mixes facts with questions about feelings

17. 1 - Preparation Know all the facts Ensure privacy
Find out who the patient would like present
Introduce yourself

18. 2 – What does the patient know?
Open ended questions
Statements may make the best questions
“How did it all start?”

19. 3 – Is more information wanted?
Not forced on them
“Would you like me to explain a bit more?”

20. 4 – Warning Shots Not straight out with it!
“I’m afraid it looks rather serious

21. 5 – Allow Denial
Allow the patient to control the amount of information they receive.

22. 6 – Explain if Requested Step by step.
Detail will not be remembered but the way you explain it will be.

23. 7 – Listen to concerns “What are your concerns at the moment?”
Allow time and space for answers.

24. 8 – Encourage Feelings Acknowledge the feelings. Non-judgmental.
Vital step for patient satisfaction.

25. 9 – Summarise Concerns. Plans for treatment. Foster hope.
? Written information.

26. 10 – Offer Further Availability. Information.
Future needs will change.

27. 1. Preparation 2. What does the patient know. 3
1. Preparation 2. What does the patient know? 3. Is more information wanted? 4. Give a warning shot 5. Allow denial 6. Explain (if requested) 7. Listen to concerns 8. Encourage ventilation of feelings 9. Summary and plan 10. Offer availability